Bruce Erickson Soccer

Bruce Erickson Soccer Application

Applicants Information	Printer Friendly Version
Camp First Name:	*
Last Name:	*
Street Adress:	*
City:		State	Zip
Email:	*
Age:	*
Grade Fall 2010:	*
Date of Birth:	*
Gender:	Male Female *
Position:	*
Payment Method:	*
	If paying by credit card, please call with card information to (402) 658-9977. *Credit Card Processing Fee is $3 for each Day Camp Application; $6 for each Residential Application.
Soccer Ball Option:	*
Which Camp:	*

Emergency Contact Information
Mother's Name:	*
Mother's Home Phone:	*
Mother's Work Phone:
Mother's Cell Phone:

Father's Name:	*
Father's Home Phone:	*
Father's Work Phone:
Father's Cell Phone:

Health Information
Current Medications:
Allergic Reactions:
Year of Last Tetanus Shot:	*

Insurance Information
Insurance Company:	*
Insurance Agent:	*
Policy Holder:	*
Policy Number:	*

Other Information
Roommate Request: (Max. 25 characters)
Coming With a Team: (Max. 30 characters)
Friends:
I hereby certify that the Creighton Soccer Community Camp staff has full and unconditional authority to proceed with diagnosis and treatment as judgement indicates for injuries during camp. The Creighton Soccer Community Camp and Creighton University shall not be held responsible for any consequence resulting from such injuries. I declare that I am the father/mother/guardian of the above-named minor.
	*
Discount: Registrations postmarked by April 1 will receive a $25 discount and a free soccer ball. (EXCLUDES LITTLE JAYS)